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DSH030022B MARICOPA MEDICAL CENTER (Terminated)
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Main Details
Name
MARICOPA MEDICAL CENTER
Subdivision Name
GLENDALE FAMILY HEALTH CENTER
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH030022B
Medicare Provider Number
030022
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/15/2016
Participating Start Date
7/1/2016
Participating Approval Date
4/20/2016
Last Recertification Date
11/5/2017
Termination Date
Termination Reason
4/1/2018
Other
Contacts
Authorizing Official
Maricopa County Special Health Care District
Richard Mutarelli, Executive Vice President, Chief Financial Officer
(602) 344-8425
Primary Contact
Maricopa Integrated Health System
Donald L Holladay, Assistant Director of Pharmacy
(602) 344-8565
Addresses
Street Address
5141 WEST LAMAR
GLENDALE, AZ 85301
Billing Address
MARICOPA MEDICAL CENTER
2601 E ROOSEVELT
PHOENIX, AZ 85008
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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4/20/16 Participated starting 1/1/1998, terminated 4/1/2012, Reinstated 7/1/2016;
04/20/2016
03/05/2012 duplicate record of FQHCLA225B
03/05/2012
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